Refocused school nurse role: early adopter evaluation

1. Background

The school health service is a universally accessible service provided to children and young people, aged 5-19 years and their families. Historically the school nursing role has played a significant part within this service. Models, roles and skill mix have varied greatly across Scotland and have encompassed; direct interventions with pupils in schools, a teaching and education focused role and a wider public health and community function. The publication of CEL 13 (2013) ^[2] aimed to redefine this role to focus on delivering consistent and more efficient services to meet current needs of the 5-19 Scottish population. The work to re-focus the School Nurse ( SN) role has been undertaken by a national Steering Group commissioned by CNO/ SEND. Since September 2015, two health boards, Dumfries and Galloway ( D&G) and Tayside (within Perth and Kinross ( P&K)) have been piloting the refocused role, including the role of the wider school health team, and associated re-design requirements. These early adopter sites are seeking to provide learning and guidance to support the impending national role out of the service.

The overarching aim of the refocus is to ensure that the SN role and service going forward delivers safe, effective and person-centred care based on the principles of Getting It Right for Every Child ( GIRFEC) national practice model.

It is proposed the future SN role will comprise two main elements:

1. Responsibility/leadership for children and families with additional healthcare needs:

Following pre-school review of children with an additional Health Plan Indicator ( HPI) at four years of age and handover from the Health Visitor, the SN will re-assess those families and children requiring on-going support. Following re-assessment, SNs will agree those children and families requiring additional support, intervention or home visit in discussion with the Named Person.

2. Focused and targeted interventions with vulnerable population groups:

It is proposed that the wider school health service remains a universally accessible service but the SN role will be more focused and targeted. School Nurses will be required to adopt the Getting It Right for Every Child National Practice Model to assess the health and well-being needs of children and young people in conjunction with the Named Person (education) role and other partners providing the health assessment component to the Child's Plan. The future role will have greater emphasis on home visiting and addressing wider policy and public health priorities, interagency working and partnerships with education and justice. In response to the available evidence base, policy direction and priorities, it was proposed that the role will be focused on nine priority areas:

• Mental health and well-being
• Substance misuse
• Child protection
• Domestic abuse
• Looked After Children
• Homeless children and families
• Children known to or at risk of involvement in the Youth Justice System
• Young Carers
• Transition points

As part of the review, it is proposed that some previous duties of school nurses may be more appropriately addressed through existing health improvement services and through the delivery of the health and well-being component of the Curriculum for Excellence.

Role of the wider school health team

The composition of the wider school health teams consisting of staff nurses, support workers, health improvement lead, education and social work link workers are likely to differ in individual Boards. However, it is proposed that they provide the universal service for all school aged children and families. This will consist of four main elements:

• Immunisation
• Screening such as height, weight, BMI. At present this takes place at P1 and sometimes P7. Following introduction of the Health Visitor review at 4 years of age the P1 screening will be reviewed. In the early adopter sites P1 assessment will be done by the wider school health team.
• Additional work commissioned by the SN
• Weekly Health Zones

Aims of the Evaluation

The aim of the evaluation was to assess how the refocused school nursing role worked in both D&G and P&K, in order to provide learning and guidance to support SN training and any further roll out and evaluation of the service.

The objectives were:

• to assess the implementation of the refocused school nursing role in the early adopter sites and identify the key facilitators and barriers to implementation.
• to explore whether the assumed mechanisms of action for the new school nurse role and wider team appear to be operating as planned, thus indicating likely future effectiveness on outcomes.
• to assess the degree to which both implementation and potential effectiveness of the school nursing role may be dependent on unique local contexts, and make recommendations for tailoring it to help inform school nursing training in future.

Structure of the report

Section one gives the background, aims and objectives of the refocused SN programme. Section two describes the realist evaluation framework used by this evaluation, and outlines the methods of data collection and analysis, Section three briefly describes the progress and structure of the implementation of the refocused role in each area and some of the background characteristics of the clients. The next three sections reflect the phases of realist evaluation. Specifically, section four uses the insights from managers who were involved in designing and implementing the refocused role to identify the initial programme theories (defined below). These theories were then tested with nurses in section five and refined in section six to provide further understanding of how the programme works.

Where quantitative data was available this was utilised in testing the programme theory. Occasionally, we have made links to the findings of the consultation with children and young people within the early adopter sites to add aditional insights. The consultation with children and young people was commissioned by the Scottish Government and conducted by Children in Scotland (Woodhouse et al., 2016).

Finally, section seven summarises the key conclusions of the evaluation and provides recommendations for any further implementation and evaluation of the school nurse programme across Scotland.

Terminology and definitions used in the report

A programme theory explains how an intervention (a project, a programme, a policy, a strategy) is understood to contribute to producing outcomes.

For the purpose of this report, we have used 'managers' to refer to those who have a supervisory or managerial role and were involved in designing and implementing the refocused SN role. We also used 'nurses' to refer to all other practitioners, including school nurses, support workers or any member of the wider school health team. However, where necessary, we distinguished between them. In addition, we use children at various points in the report to refer to those who use the service but in essence they refer to both children and young people.